How Much Bowel to Resect

Unlike in large-bowel involvement, in the case of Crohn's disease affecting the small intestine, surgical procedure is standardised. The role of surgery in CD is limited to the treatment of complications which do not respond to conservative therapy. In contrast to ulcerative colitis, CD is incurable. The high percentage of recurrences after surgery in this group is the reason for limitations in surgical procedures. The percentage of recurrences is estimated to be 55% during the 15-year period after the first surgical procedure [27]. Short-bowel syndrome is one of the most serious complications after surgery of CD with the localisation in the small intestine. Multiple laparotomies and intestinal resections result in a decrease of the total length of the small intestine. When the length of the intestine falls below 2 m, serious clinical problems appear. The introduction of new operating techniques—strictureplasty—has limited this complication considerably [34]. The strategy of surgical intervention in the treatment of complications of CD related to small intestine is clear—one should strive for the most sparing operation possible.

The fundamental question which should be asked before elective surgery relates to the possibility of preserving the continuity of the digestive tract, which mainly depends on the presence of rectal manifestations, the type of complication, location and duration of the disease as well as the general state of the patient [29]. The range of intervention options on the large bowel is not as limited as that of the small bowel. There is no risk of systemic disturbances even in vast resections of the colon. When changes affect short fragments of the large intestine, simple resection of the affected part of the intestine is an alternative to colectomy. This kind of intervention is less debilitating for the patient and the physiology of large intestine can also be kept. The limitation of this method is the high risk of recurrence, which is estimated at about 60% after 5 years from the first intervention [33]. Recurrence is more frequent in patients with changes in the distal part of colon [22]. Hence this group should qualify for proctocolectomy with ileostomy. Colectomy with ileo-rectal anastomosis is, however, preferable for young patients with no involvement of the sigmoid colon and/or rectum; the majority of these patients have normal bowel motions even after 10 years.

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